- In RBBB, activation of the right ventricle is delayed as depolarisation has to spread across the septum from the left ventricle.
- The left ventricle is activated normally, meaning that the early part of the QRS complex is unchanged.
- The delayed right ventricular activation produces a secondary R wave (R’) in the right precordial leads (V1-3) and a wide, slurred S wave in the lateral leads.
- Delayed activation of the right ventricle also gives rise to secondary repolarization abnormalities, with ST depression and T wave inversion in the right precordial leads.
- In isolated RBBB the cardiac axis is unchanged, as left ventricular activation proceeds normally via the left bundle branch.
ECG changes in RBBB
- Broad QRS > 120 ms
- RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
- Wide, slurred S wave in the lateral leads (I, aVL, V5-6)
- ST depression and T wave inversion in the right precordial leads (V1-3)
- Sometimes rather than an RSR’ pattern in V1, there may be a broad monophasic R wave or a qR complex.
Causes of RBBB
- Right ventricular hypertrophy / cor pulmonale
- Pulmonary embolus
- Ischaemic heart disease
- Rheumatic heart disease
- Myocarditis or cardiomyopathy
- Degenerative disease of the conduction system
- Congenital heart disease (e.g. atrial septal defect)
More ECG Examples of RBBB
- Incomplete RBBB is defined as an RSR’ pattern in V1-3 with QRS duration < 120ms.
- It is a normal variant, commonly seen in children (of no clinical significance).
Differential Diagnosis of RBBB
- An RSR’ pattern in V1-3 may also be caused by Brugada syndrome — an ECG pattern associated with malignant ventricular arrhythmias.
- Hampton, JR. The ECG In Practice, 6e
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
- Wagner, GS. Marriott’s Practical Electrocardiography 12e
- Chan, TC. ECG in Emergency Medicine and Acute Care
- Mattu, A. ECG’s for the Emergency Physician
LITFL Further Reading
- ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis –alphabetical diagnostic approach to the ECG
- ECG CLINICAL CASES — ECG’s placed in clinical context with a challenging Q&A approach
- 100 ECG Quiz — Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS — the best of the rest
- LITFL ECG IMAGE Database — Searchable database of LITFL ECG’s
- ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
- ECG Exam Template — a framework for answering ECG exam questions.